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Clinical Management of Hypertensive Heart Disease: Preventing Heart Failure

Clinical Management of Hypertensive Heart Disease: Preventing Heart Failure. Clyde W. Yancy, MD, FACC, FAHA, FACP Medical Director, Baylor Heart and Vascular Institute Chief, Cardiothoracic Transplantation Baylor University Medical Center Dallas, Texas.

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Clinical Management of Hypertensive Heart Disease: Preventing Heart Failure

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  1. Clinical Management of Hypertensive Heart Disease:Preventing Heart Failure Clyde W. Yancy, MD, FACC, FAHA, FACP Medical Director, Baylor Heart and Vascular Institute Chief, Cardiothoracic Transplantation Baylor University Medical Center Dallas, Texas

  2. Prevalence of Heart Failure Increases With Age* 10 Male 8 Female 6 Population (%) 4 2 0 20–24 25–34 35–44 45–54 55–64 65–74 75+ Age (yr) *NHANES, 1999-2002. NHANES=National Health and Nutrition Examination Survey. Adapted from American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, TX: American Heart Association; 2005.

  3. From Risk Factors to Heart Failure: The Cardiovascular Continuum Myocardial infarction Arrhythmia Coronary thrombosis Loss of muscle Myocardial ischemia Sudden death B CAD Remodeling A Atherosclerosis LVH Ventricular dilatation • Risk factors • Hyperlipidemia • Hypertension • Diabetes • Insulin resistance Heart failure c Death D Adapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.

  4. Risk Factors for CHF Among Hypertensive Subjects* 1 2 4 6 8 10 CHF=congestive heart failure; CI=confidence interval. * Based on 165 CHF events in 1707 men and 192 events in 2118 women with hypertension prior to CHF. Based on dynamic model with reclassification of hypertension and risk factors at each follow-up examination. †Adjusted for myocardial infarction,angina pectoris, diabetes, left ventricular hypertrophy, and valvular heart disease. Adapted from Levy D, et al. JAMA. 1996;275:1557–1562.

  5. HF Algorithm HF At Risk for HF STAGE D Refractory HF requiring specialized interventions. STAGE C Structural heart disease with prior or current symptoms of HF. STAGE B Structural heart disease but without signs or symptoms of HF. STAGE A At high risk for HF but without structural heart disease or symptoms of HF. • eg, Patients with: • Hypertension • Atherosclerotic disease • Diabetes • Obesity • Metabolic syndrome or • Patients • Using cardiotoxins • With family history of cardiomyopathy • Therapy Goals • Treat hypertension • Encourage smoking cessation • Treat lipid disorders • Encourage regular exercise • Discourage alcohol intake, illicit drug use • Control metabolic syndrome • Drugs • ACEI or ARB in appropriate patients for vascular disease or diabetes ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker.

  6. JNC 7: The Hypertension Guidelines

  7. New Features and Key Messages • For persons over age 50, SBP is more important than DBP as CVD risk factor • Starting at 115/75 mm Hg, CVD risk doubles with each increment of 20/10 mm Hg throughout the BP range • Persons who are normotensive at age 55 have a 90% lifetime risk for developing hypertension • Those with SBP 120-139 mm Hg or DBP 80-89 mm Hg require health-promoting lifestyle modifications to prevent CVD andshould be considered prehypertensive SBP=systolic blood pressure; DBP=diastolic blood pressure; CVD=cardiovascular disease.

  8. New Features and Key Messages (cont’d) • Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes • Certain high-risk conditions are compelling indications for other drug classes • Most patients will require ≥2 antihypertensive drugs to achieve goal BP • If BP is >20/10 mm Hg above goal, initiate therapy with 2 agents, 1 usually should be a thiazide-type diuretic

  9. Without Compelling Indications With Compelling Indications Drug(s) for the Compelling Indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed Stage 1 Hypertension(SBP 140-159 or DBP 90-99 mm Hg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination Stage 2 Hypertension(SBP >160 or DBP >100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB) Not at Goal BP Optimize dosages or add additional drugs until goal BP is achieved.Consider consultation with hypertension specialist Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal BP (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease) Initial Drug Choices BB=β-blocker; CCB=calcium channel blocker.

  10. Compelling Indications for Individual Drug Classes THIAZ=thiazide; NKF-ADA=National Kidney Foundation-American Diabetes Association; UKPDS=UK Prospective Diabetes Study; ALLHAT=Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; RENAAL=Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan; IDNT=Irbesartan in Diabetic Nephropathy Trial; AASK=African American Study of Kidney Disease and Hypertension; PROGRESS=Perindopril Protection Against Recurrent Stroke Study.

  11. Does Treatment of Hypertension Prevent HF?

  12. Optimal BP control: Optimal BP control in patients with prior MI: Treatment of Hypertension Decreases risk of new HF by 50% Decreases risk of new HF by 80% MI=myocardial infarction. Dahlöf B, et al. Lancet. 1991;338:1281-1285. Kostis JB,et al. JAMA. 1997;278:212-216.

  13. The Pyramid of HF and Potential Impact of a Range of Preventive and Treatment Strategies in Lowering Age-Specific Mortality Percent Type of Intervention Impact Class IV HF + <0.2 Transplantation; Tiny low ejection fraction left ventricular assist device, implantable cardiac defibrillator Any CHF <2 ACEIs, ß-blockers, Modest spironolactone High-risk individuals <20 Antihypertensive therapy; Moderate (eg, those with hypertension drugs to lower cholesterol, or who have had an ACEIs, smoking MI) cessation Obese or overweight >40 Weight loss, plus above Large individual (eg, body mass measures index >25), plus those in above category Affected (40+ y) Adapted from Yusuf S, et al. Circulation. 2002;106:2997-2998.

  14. UKPDSHypertension Study:Benefits of 144/82 vs 154/87 • Tight BP control, with either a β-blocker or an ACEI, in type 2 diabetes decreases1: • Death related to diabetes by - 32% • Stroke by - 44% • Microvascular disease by - 37% • HF by - 56% • Progression of retinopathy by - 34% • Deterioration of visual acuity by - 47% • BP target <130/80 for patients with diabetes and in chronic renal disease, JNC 72 1. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713. 2. National Institutes of Health, National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, MD: National Institutes of Health; December 2003. NIH Publication No. 03-5233.

  15. Minority Populations • In general, treatment similar for all demographic groups • Socioeconomic factors and lifestyle important barriers to BP control • Prevalence, severity of hypertension increased in African Americans • African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs • These differences usually eliminated by adding adequate doses of a diuretic

  16. Hypertension in African Americans • 3-7 times more prevalent in African American vs nonAfrican American1 • Higher incidence of ESRD due to hypertension1 • Higher risk of stroke2 • Increased mortality due to stroke1 • Higher incidence of LVH, 31% vs 10%1 • The above likely represents a more malignant vascular response to hypertension1 • Optimal adherence to hypertension guidelines is imperative in this high-risk group1 ESRD=end-stage renal disease; LVH=left ventricular hypertrophy. 1. Yancy CW. J Card Fail. 2000;6:183-186. 2. American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas, TX: American Heart Association; 2006.

  17. HF in African Americans: Overview • Affects 3% of the African American population1 • Atypical natural history2 • Unique epidemiology3,4 • Lower prevalence of ischemic heart disease4 • More likely associated with history of hypertension4 • Worrisome prognosis2,5 • Higher rate of hospitalization5 • ? Question of altered responses to medical therapy2 1. American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas, TX: American Heart Association; 2006. 2. Yancy CW. J Card Fail. 2000;6:183-186. 3. Philbin EF, et al. Am J Cardiol. 1998;82:76-81. 4. Mathew J, et al. Am J Cardiol. 1996;78: 1447-1450. 5.Dries DL, et al. N Engl J Med. 1999;340:609-616.

  18. New Directions

  19. TROPHY Results: Trends in SBP placebo candesartan difference placebo - candesartan Difference in BP (mm Hg) -2.0 -10.4 SBP (mm Hg) Month Adapted from Julius S, et al. N Engl J Med. 2006;354:1685-1697.

  20. TROPHY Conclusions • Over 4 years, nearly two-thirds of the placebo group developed stage 1 treatment-requiring hypertension • In patients with prehypertension, 2 years of treatment with the ARB candesartan 16 mg/d: • Delayed onset of stage 1 hypertension for up to 2 years after discontinuation of treatment • Substantially suppressed development of stage 1 hypertension during the 2 years of active treatment • Substantially prolonged the hypertension-free period throughout the trial • Was well tolerated Julius S, et al. N Engl J Med. 2006;354:1685-1697.

  21. AliskirenBP Reduction • Placebo • Aliskiren 150 mg • Aliskiren 300 mg • Aliskiren 600 mg sys sys sys sys dias dias dias dias * * * * † * n=165 n=172 n=169 n=166 *P<.0001 for all doses vs placebo. †P<.05 for 600 mg compared to 150 mg. Oh BH, et al. J Am Coll Cardiol. 2007;49:1157-1163.

  22. From Risk Factors to Heart Failure: The Cardiovascular Continuum Myocardial infarction Arrhythmia Coronary thrombosis Loss of muscle Sudden death Myocardial ischemia B CAD Remodeling A Atherosclerosis LVH Ventricular dilatation • Risk factors • Hyperlipidemia • Hypertension • Diabetes • Insulin resistance Heart failure c Death D Adapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.

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